Provider Demographics
NPI:1891859633
Name:SCHULTZ, MELISSA KELLOGG (OD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:KELLOGG
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3213 TAMARRON DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1248
Mailing Address - Country:US
Mailing Address - Phone:248-375-5634
Mailing Address - Fax:
Practice Address - Street 1:1301 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-7017
Practice Address - Country:US
Practice Address - Phone:248-643-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004217152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU98045Medicare UPIN